Online Letters to the Editor

Influence of Video Games on Children's Health

to the editor: I enjoyed reading the Medicine and Society feature,1 "Counseling Patients on Mass Media and Health," written by Dr. Primack in American Family Physician.

I would like to point out the rising influence of video games on today's youth. The video game industry is an estimated $10 billion-per-year business, worth more than the television or film industry. According to recent surveys, television ratings between the hours of 5 p.m. and 11 p.m. have decreased among teenagers, while video game use has increased during this time slot. In a 2001 consumer survey distributed by the Interactive Digital Software Association, respondents ranked playing video games as the best form of entertainment ahead of watching television, surfing the Internet, or going to the movies.

Todays video games are becoming exponentially more complex with astoundingly realistic graphics, intricate plots, and lengthy playing times. Some games have million dollar production budgets and massive marketing campaigns. In addition, video games are geared more and more toward the adult population, including such themes as war, murder, drugs, and sex.

Video games are regulated by the Entertainment Software Rating Board (ESRB), an independent, voluntary rating system established in September 1994 after much congressional pressure. The ESRB applies age-specific ratings ranging from "Early Childhood" (three years and older) to "Adults Only" (18 years and older). In addition, the ESRB provides content descriptors for the games, indicating the presence of violent content, sexual themes, and mature language. However, two studies2,3 have demonstrated that a significant amount of violent content exists in games rated "E for Everyone" (six years and older) and "T for Teen" (13 years and older). The same holds true for other adult themes such as sex, drugs, and gambling. It is apparent that the rating system is not foolproof and perhaps should be modified to avoid exposing young children to age-inappropriate content.

A number of adverse health effects have been linked to video game use in children, ranging from obesity4 to the possibility of violent and aggressive behavior.5 Video games also appear to have the potential for addiction, with reports of children playing certain games for more than 40 hours per week. There has even been a case6 of a 15-year-old boy who developed tendonitis after playing video games for up to seven hours a day using a vibrating joystick. However, some studies show potentially beneficial aspects to video game play, including improved hand-eye coordination and visual attention.

What can physicians do? We should counsel parents on the unsuitable material to which their children may be exposed during video game use. I also recommend that the total amount of time playing video games be limited to one to two hours per day. In addition, parents should consider playing the games with their children and being aware of all the games they may be purchasing.

ADAM DIMITROV, M.D.

Franklin Square Hospital
9100 Franklin Square Dr.
Baltimore, MD 21237

REFERENCES

Population-Based Strategy to Reverse the Obesity Epidemic

to the editor: While the interventions listed in the article1 on obesity in children and adolescents by Fowler-Brown and Kahwati address clinical practice in depth, experience with tobacco control has shown that changing individual behavior requires structural and societal supports to achieve the desired results. The most effective solutions to the obesity epidemic will likely involve policies and environments that encourage healthy food and physical activity choices. Regulatory policies; consumer education that addresses marketing, health claims, and nutrition labeling; and school strategies will all be necessary to reverse current trends.

Changes to encourage physical activity can be implemented on a small scale. For instance, secure bike storage and shower facilities can be made available, and the location, safety, and appearance of stairwells can be improved. Community designs that locate neighborhoods convenient to shopping, work sites, libraries, and schools require more substantial long-term planning and political support. Child-oriented features that encourage physical activity include safe, available playgrounds and traffic infrastructure that increases the safety of walking or biking to school.

School vending machines and cafeterias that offer diverse, attractive, and well-priced alternatives to unhealthy foods have been shown to make nutritious choices more competitive.2 Compared with more affluent families, those living in high-poverty areas often have less access to low-cost nutritious food and depend on high-priced, calorie-dense processed foods from convenience stores. Zoning and tax incentives that encourage larger grocery stores to locate in less affluent neighborhoods are as important as nutrition education. Promotions such as the "5-A-Day" program to increase the consumption of fruits and vegetables do not work well if those foods are not available.

Financial pressures force hard choices on under-funded school. School nutrition programs may rely on revenue from snack sales, as do other worthy extracurricular programs. Emphasis on academic basics cuts into nutrition and physical activity curricula.3,4 Fortunately for policy makers, the societal costs of obesity help justify the costs of interventions. Public recognition also is shifting; some of the most financially strapped school districts have banned soda-pouring contracts because of the financial incentives to increase consumption among children and adolescents.

Increased awareness of the extent of obesity and its health consequences is inadequate to resolve the problem, as are education and weight reduction interventions for individuals. A comprehensive, population-based strategy, similar to the anti-tobacco strategies, will be needed. Analogous to the tobacco example, corporate interests have reasons and resources to oppose the regulation of marketing and sales, especially to children. Advocates must be willing to become politically active and adept. The positions of the American Academy of Family Physicians on nutrition and physical activity in schools are worthy guidelines, and family physicians are ideal champions for the necessary changes.5

KATHLEEN MCAULIFFE, M.D., M.P.H.

3218 SE 75TH
Portland, OR 97206

REFERENCES